A physician who is afraid of shots

This is not a story about anti-vaxxers. This is a story about primary care.

Running a smaller practice, as I do, has inherent rewards and challenges. There is literature on both sides of the Atlantic that patients prefer small practices. Lately, consolidation of practices has been frequent, mostly under the auspices of hospitals, sometimes into larger private groups. Although vertical integration appears to have increased costs and by various mechanisms inadvertently shut out small practices, and although there’s good literature that small practices do some things better than larger practices, it may not really matter where people receive care. What matters is continuity and access to someone who knows you in a timely fashion.

Along with that, we know from the work of John Wasson that confidence in managing one’s health care and knowing when and how to call for help is a key driver of improved outcomes.

But access to vaccines, a key part of care, remains challenging, especially for small practices. While we have state VFC programs and the adverse event reporting system, vaccine rates for both children and adults are less than optimal.

The reasons for this are multiple and complex — insurance coverage and cost, misinformation, visits that are too busy to get everything done. But we never really talk about the tools that primary care needs to provide vaccines.

One thing we need is access to vaccines in unit doses. Most vaccines, although not all, come in unit doses inside sealed boxes of five or, usually, 10. Providers must get ten doses at a time.

In a large practice, this makes sense. In a small practice, vaccines are a large expense or — if obtained through the VFC — they expire and are wasted. Although they can be sent back for credit, here in Maine if this happens too often, the practice has to pay for wasted vaccines that they didn’t want in the first place. If you don’t have a state program, practices still access too many at a large expense ( $2,000.00 for ten doses of several vaccines), then return expired ones for credit. This is a time waster, though less punitive.

Schools have stopped giving flu shot clinics because of the policy — they don’t have money to pay for what they don’t use. Instead of constructing complex formulas about the allowance for waste before providers are charged, leadership should advocate with the manufacturers to give primary care the tools that it needs to serve its population.

Vaccines have to be kept at narrow temperature ranges. Many offices have been through several rounds of refrigerators and freezers. Many of us learn how much the temperature inside a refrigerator can vary, to our incredible dismay. While some states provide temperature monitoring devices, the devices don’t load up to the state site, and so, despite USB ports and downloading to view the temps, providers still have to log on to state sites and electronically color in four dots a day to document temps. opening, closing, maximum, minimum. Also, color in dots to indicate if the office was closed that day. There is an app —not made available to us — for the device to load right up to the state. If one of these devices break, it is not easy to get information on how to fix it. I speak from personal experience.

When we talk about increasing vaccination rates, those of us on the front line know that if we can give shots when the patient is here, they are more likely to get vaccinated. Sending an adult to the pharmacy means they might not get that Pneumovax or two Shingrix (and if they do, PCPs have extra work adding it to the EMR. I guess that is after we have colored in all those dots.), but the manufacturers will not sell us what we need. Although most of these vaccines come in single-dose vials, providers cannot access them.

I have called and written Merck and Sanofi about this for years.

In order to get us what we need, the manufacturers would have to ask the FDA for new NDC numbers. The NDC is a kind of packaging code. That’s all it would take.

Our professional societies should be advocating for this. This makes an enormous difference in practices’ ability to care for young children. While there still may be issues around coverage, the VFC program helps with that, but having practices replace hundreds of dollars’ worth of vaccines because they were forced to stock too many is not sustainable. Our professional societies should be on this.

In fact, a really good idea for vaccine management is to centralize it, because it’s becoming more and more complex as there are more and more vaccines — and they are more complicated.

Think about just the flu vaccine. There are quadrivalent, trivalent and recombinant; sometimes there is live nasal vaccine. There’s a smaller dose repeated in a month if it’s a child’s first vaccine and a smaller dose not repeated if under age … is it nine? How easy to make a mistake.

Primary care funding in this country is about seven percent of total health expenditures, I am told. It is 20 percent in other countries. Primary care providers need more tools to do their work, not more complexity.

Sanofi and Merck need to be told by our professional societies what we need. They are the biggest manufacturers. This should be a win-win for them as they would sell more vaccine. Ideally, public health nursing clinics should be held the way even small towns manage rabies clinics. Recall the jokes about why my cat gets a reminder postcard and a magazine from the vet, but its owners don’t get one from the doctor.

That’s because in health care we just don’t have systems that work.

Professional societies need to step up and help providers reduce the burdens associated with giving shots.

Then I wouldn’t be so afraid.

Jean Antonucci is a family physician and can be reached at her self-titled site, Jean Antonucci.